Form Com 2569 - Application For Automatic Extension Of Time To File The Annual Report Of Unclaimed Funds - Ohio Division Of Unclaimed Funds

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John R. Kasich
OHIO DIVISION OF UNCLAIMED FUNDS
Governor
Andre T. Porter
77 S. High St., 20th Floor Columbus, OH 43215-6108, (877) 644-6823, FAX (614) 728-9769 Federal Tax ID# 31-1409347
Director
Application for Automatic Extension of Time
To File the Annual Report of Unclaimed Funds
Company Information
Holder Name
FEIN OR SSN
Address
Contact Phone Number
City, State, Zip Code
Contact email Address
Name of Contact Person
State of Inc. / Organization
Report Year
Contact Person Title
I request an automatic extension of:
All Holders Except
Extension
Life Insurance Co.'s
Life Insurance Co.'s
December 1st
June 1st
30 DAYS UNTIL
January 1st
July 1st
60 DAYS UNTIL
February 1st
August 1st
90 DAYS UNTIL
March 1st
September 1st
120 DAYS UNTIL
from the original due date of November 1 (May 1 for Life Ins. Co.’s) to file the
Annual Report of Unclaimed Funds for the company identified above.
Signature
Title or Agent Relationship
Print Name
Date
INSTRUCTIONS: Use this Application to obtain an automatic extension of time to file
your Annual Report of Unclaimed Funds beyond November 1 (May 1 for Life Insurance
Companies). Please include your company’s Federal Tax ID (FEIN). Specify how long
an extension is needed by placing a check mark in one of the boxes indicating the
extended due date. The Application will not be accepted without a signature and a
FEIN. Mail the Application to the Ohio Division of Unclaimed Funds, 77 S. High
St., 20th Floor, Columbus, OH 43215-6108 or fax it to (614) 728-9769. THE
EXTENSION IS AUTOMATIC UPON FILING THIS FORM, NO CONFIRMATION
WILL BE SENT.
COM 2569 revised 5/2002

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